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Adult Vaccination Coverage — United States, 2010

Immunizations are recommended throughout life to prevent infectious diseases and their sequelae. Adult coverage, however, remains low for most routinely recommended vaccines (1) and well below Healthy People 2020 targets. In October 2011, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2012 (2). Apart from influenza vaccination, which is now recommended for all adults, other adult vaccines target different populations based on age, certain medical conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications (2). To assess adult (≥19 years) vaccination coverage for select vaccines, CDC analyzed data from the 2010 National Health Interview Survey (NHIS). This report summarizes the results of that analysis for pneumococcal, hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines, as well as tetanus antigen–containing vaccines (including tetanus, diphtheria, and acellular pertussis vaccine [Tdap]), by selected characteristics (age, vaccination target group status, and race/ethnicity). Influenza vaccination coverage estimates for the 2010–11 influenza season have been published separately (3). Compared with results of the 2009 NHIS survey (1), increases in coverage were observed only for Tdap vaccination for persons aged 19–64 years (1.6 percentage point increase to 8.2%), zoster vaccination among persons aged ≥60 years (4.4 percentage point increase to 14.4%), and ≥1 dose HPV vaccination in women aged 19–26 years (3.6 percentage point increase to 20.7%); coverage for the other vaccines was unchanged at <70%. These data indicate only limited recent improvements in vaccination coverage among adults in the United States. Substantial increases are needed to reduce the occurrence of vaccine-preventable diseases among adults.

NHIS collects information about the health and health care of the noninstitutionalized, civilian population in the United States using nationally representative samples. Interviews are conducted in respondents' homes. Questions about receipt of recommended adult vaccinations are asked of a randomly selected adult within the household. Definitions of high risk conditions* are based on ACIP recommendations for each vaccine (2). Additional analyses were conducted to estimate baseline coverage of persons with diabetes who recently were recommended for hepatitis B vaccination and for males recommended for quadrivalent HPV vaccination if aged ≤21 years or aged 22–26 years and at higher risk for HPV infection (4,5). Weighted data† were used to produce national estimates. Point estimates and estimates of corresponding variances were calculated using statistical software to account for the complex sample design. Statistical significance was defined as p<0.05.

In 2010, the proportion of adults receiving any tetanus toxoid–containing vaccination (i.e., tetanus and diphtheria toxoid [Td] or Tdap) during the past 10 years was 64.0% for adults aged 19–49 years, 63.4% for adults aged 50–64 years, and 53.4% for adults aged ≥65 years (Table 1). The proportion of adults receiving tetanus vaccination during the past 10 years across all age groups did not change compared with 2009 (1). Non-Hispanic whites had higher coverage across all age groups compared with non-Hispanic Asians, Hispanics, and non-Hispanic blacks.

Among adults aged 19–64 years for whom Tdap status specifically could be assessed, Tdap vaccination coverage was 8.2% (Table 1). Tdap coverage was estimated after excluding respondents without a "yes" or "no" classification for tetanus vaccination status within the preceding 10 years (n = 1,081 [5.1%] of 21,041) or tetanus vaccination status during 2005–2010 (n = 589 [2.8%] of 21,041), and those who reported tetanus vaccination during 2005–2010, but were not told (n = 4,124 [19.6%] of 21,041) or did not know the vaccine type (Td or Tdap) (n = 665 [3.2%] of 21,041). Among 7,088 respondents who received a tetanus vaccination during 2005–2010, 58.9% reported that they were not informed of the vaccination type, and 9.6% could not recall what type of tetanus vaccination they had received (Table 2). Of the remaining respondents, 52.3% reported receiving Tdap (Table 2).

Compared with 2009, Tdap coverage increased for persons aged 19–64 years overall (1.6 percentage point increase to 8.2%), and among non-Hispanic Asians (4.8 percentage point increase to 9.2%), non-Hispanic whites (1.7 percentage point increase to 9.1%), and persons without household contact with an infant aged <1 year§ (1.7 percentage point increase to 8.1%); however, Tdap coverage remained low (Table 1). Non-Hispanic whites had higher Tdap coverage (9.1%) compared with non-Hispanic blacks (7.4%) and Hispanics (4.8%). Tdap coverage for persons with household contact with an infant aged <1 year (10.6%) was similar to coverage for non-Hispanic whites (Table 1).

During 2005–2010, Tdap vaccination of health-care personnel (HCP) overall (20.3%) was higher compared with the 2009 estimate (13.2%) (Table 3). Non-Hispanic white HCP had higher Tdap coverage (21.5%) compared with non-Hispanic black HCP (14.0%) and Hispanic HCP (13.8%). HCP were more likely to have received Tdap as a tetanus vaccination (63.2%) than adults who were not HCP (52.3%) (Table 2).

Hepatitis A Vaccination Coverage

Hepatitis A vaccination coverage (≥2 doses) among adults aged 19–49 years was low overall (10.7%), and similar to the estimate for 2009 (9.8%). Vaccination coverage among adults aged 19–49 years was higher (16.6% versus 7.5%) among persons who traveled to countries of high or intermediate endemicity outside the United States (other than to Europe, Japan, Australia, New Zealand, or Canada) since 1995, compared with respondents who traveled only within the United States, Europe, Japan, Australia, New Zealand, or Canada (Table 1). Coverage was higher for non-Hispanic Asians (15.3%) and adults aged 19–49 years who indicated a race other than Asian, black or white and non-Hispanic ethnicity (16.5%) than for other groups (Table 1).

Hepatitis B Vaccination Coverage

In 2010, hepatitis B vaccination coverage (≥3 doses) among adults aged 19–49 years at high risk for infection (42.0%) was similar to the 2009 estimate (41.8%) (Table 1). Vaccination coverage for persons aged 19–49 years at high risk for infection was 44.5% for non-Hispanic whites, 41.6% for non-Hispanic blacks, and 40.2% for non-Hispanic Asians, but was lower for Hispanics (33.8%) compared with non-Hispanic whites. Overall, vaccination coverage was higher for adults aged 19–49 years at high risk for infection (42.0%), compared with adults aged 19–49 years not at high risk for infection (33.1%). Vaccination coverage for persons with diabetes aged 19–59 years and ≥60 years was 22.8% and 10.9%, respectively. Overall, hepatitis B vaccination coverage among HCP was 63.2%; coverage did not differ significantly across racial/ethnic groups (Table 3) nor when compared with 2009 coverage.

In 2010, 20.7% of women aged 19–26 years reported receipt of ≥1 dose of HPV vaccine, an increase from 17.1% reported for 2009 (Table 1), and a further increase from 10.5% reported for 2008 (1,6). Hispanics had lower coverage (15.1%) compared with non-Hispanic whites (22.4%), but coverage across racial/ethnic groups otherwise did not differ (Table 1). Fewer than 1% of males aged 19–26 years received ≥1 dose of HPV vaccine in 2010 (Table 1).

Editorial Note

In 2010, noninfluenza adult vaccination coverage was similar to 2009, except for modest increases in Tdap, HPV, and zoster vaccine coverage in certain groups. Many adults have not received one or more recommended vaccines. Vaccination coverage estimates for the three vaccines in this report that are included in Healthy People 2020 (pneumococcal, herpes zoster, and hepatitis B [for HCP] vaccines) are well below the respective target levels¶ of 90% for persons aged >65 years and 60% for persons aged 18–64 years at high risk (pneumococcal vaccine), 30% (herpes zoster vaccine), and 90% (hepatitis vaccine [for HCP]). These data indicate little progress was made in improving adult coverage in the past year and highlight the need for continuing efforts to increase adult vaccination coverage.

In October 2011, ACIP recommended hepatitis B vaccination of previously unvaccinated adults aged <60 years who have diabetes as soon as possible after diabetes is diagnosed, and that adults aged ≥60 years with diabetes be considered for hepatitis B vaccination after assessing their risk and likelihood of immune response (2,4). The recommendations were based on findings from studies indicating increased risk for contracting acute hepatitis B among persons with diabetes (7,8) and a trend for higher mortality among acute hepatitis B virus–infected persons with diabetes compared with persons without diabetes (CDC, unpublished data, 2011).

Assisted monitoring of blood glucose and other procedures in which instruments or parenteral treatments are used in different persons sequentially without appropriate infection control procedures can result in percutaneous exposure to hepatitis B virus. Increasing hepatitis B vaccination among persons with diabetes and improving infection control practices during diabetes monitoring and care might decrease the occurrence of hepatitis B infection in this population. Diabetes will be included as a risk factor for hepatitis B infection in future determinations of overall coverage among persons with high-risk conditions.

Also in October 2011, ACIP recommended routine HPV vaccination for males aged 11–12 years and vaccination of males aged 13–21 years who have not been vaccinated previously; males aged 22–26 years also may be vaccinated against HPV. For immunocompromised males (including males with human immunodeficiency virus [HIV] infection), and for men who have sex with men, ACIP recommended routine vaccination through age 26 years for those not vaccinated previously (2,5). These recommendations replace the October 2009 ACIP guidance that HPV vaccine may be given to males aged 9–26 years. Since 2006, ACIP has recommended routine HPV vaccination for females aged 11–12 years and vaccination of females aged 13–26 years who previously have not been vaccinated against HPV (2). The percentage of age-eligible females administered HPV vaccine is low but increasing. The primary target group for HPV vaccine is girls and boys aged 11–12 years.

The findings in this report are subject to at least two limitations. First, the determination of vaccination status and identification of high-risk conditions in NHIS were not validated by medical records. Self-report of vaccination is subject to recall bias and might result in overestimation of rates. Adult self-reported pneumococcal vaccination status, however, has been shown to be sensitive and specific (9). Second, the Tdap estimate is subject to considerable uncertainty. Many respondents were excluded from estimations of Tdap coverage, creating a potential for bias. All respondents who reported a tetanus vaccination during 2005–2010, but were unable to say whether Td or Tdap was used, were excluded. Sensitivity calculations were conducted to assess the magnitude of potential bias. Depending on what proportion of excluded respondents actually received Tdap, actual Tdap coverage could fall within the range of 6.1%–31.6%. Comparisons of Tdap coverage across years within subgroups might be affected by bias resulting from excluding persons who did not report the type of tetanus vaccine they received.

Substantial improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults. Successful vaccination programs combine education of potential vaccine recipients and publicity to promote vaccination, increased access to vaccination services in medical and complementary settings such as workplaces and commercial establishments (e.g., pharmacies), and use of practices shown to improve vaccination coverage, including reminder-recall systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members (10). Annual publication of the adult immunization schedule (2) provides the most current recommendations for vaccinating adults and can provide a ready resource for persons who administer vaccine to adults in various settings.

CDC. Final state specific influenza vaccination coverage estimates for the 2010–11 season—United States, National Immunization Survey and Behavioral Risk Factor Surveillance System, August 2010 through May 2011. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm. Accessed January 9, 2012.

* Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; or they had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months; or had an asthma episode or attack; or were current smokers. Adults were considered at high risk for hepatitis A or B if they had hemophilia and had received clotting factor concentrations, were a man who had sex with other men, had taken street drugs by needle, had traded sex for money or drugs, had tested positive for human immunodeficiency virus (HIV), or had sex with someone who would meet any of the previous criteria; considered themselves at high risk for HIV infection, or reported having a sexually transmitted diseases other than HIV or acquired immunodeficiency syndrome (AIDS) during the previous 5 years.

§ A single dose of Tdap is recommended for adults who have or who anticipate having close contact with an infant aged <1 year (e.g., parents, grandparents aged <65 years [adults ≥65 may receive Tdap], child-care providers, and health-care personnel) to reduce the risk for transmitting pertussis.

From 2008 to 2009, U.S. coverage with routinely recommended vaccinations among adults aged ≥19 years remained low.

What is added by this report?

Compared with 2009 estimates, tetanus, diphtheria, and acellular pertussis (Tdap) vaccination in 2010 increased to 8.2%, herpes zoster vaccination for non-Hispanic whites and non-Hispanic Asians aged ≥60 years increased to 16.6% and 12.7%, respectively, and women aged 19–26 years reporting receipt of ≥1 dose of human papillomavirus (HPV) vaccine increased to 20.7%. New populations were advised in October 2011 to receive hepatitis B and HPV vaccination. Among persons with diabetes, hepatitis B vaccination coverage in 2010 was 22.8% for those aged 19–59 years and 10.9% for those aged ≥60 years. Among males aged 19–26 years, <1% had received ≥1 dose of HPV vaccine as of 2010.

What are the implications for public health practice?

Coverage remains low for most vaccines routinely recommended for adults. Wider use of practices shown to improve adult vaccination is needed, including implementing reminder-recall systems, use of standing order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members.

TABLE 1. Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* and race/ethnicity† — National Health Interview Survey, United States, 2010

Characteristic

Sample size

%

(95% CI)

Difference from 2009

Pneumococcal vaccination, ever§

19–64 yrs, high risk

Total

7,624

18.5

(17.4–19.6)

1.0

White, single race, not Hispanic or Latino

4,478

19.0

(17.7–20.4)

0.8

Black, single race, not Hispanic or Latino

1,388

18.6

(16.4–21.1)

0.9

Hispanic or Latino

1,239

14.8

(12.7–17.2)¶

2.7

Asian, single race, not Hispanic or Latino

296

11.5

(7.9–16.5)¶

-4.8

Other race/ethnicity

223

26.0

(19.2–34.3)

6.8

≥65 yrs

Total

5,209

59.7

(58.0–61.4)

-1.0

White, single race, not Hispanic or Latino

3,577

63.5

(61.6–65.4)

-1.3

Black, single race, not Hispanic or Latino

781

46.2

(41.8–50.6)¶

1.5

Hispanic or Latino

551

39.0

(34.2–43.9)¶

-1.2

Asian, single race, not Hispanic or Latino

246

48.2

(41.6–54.9)¶

3.3

Other race/ethnicity

54

58.4

(40.9–74.1)

4.1

Tetanus vaccination, past 10 years**

19–49 yrs

Total

13,946

64.0

(63.0–65.0)

0.9

White, single race, not Hispanic or Latino

7,061

69.3

(68.0–70.6)

1.0

Black, single race, not Hispanic or Latino

2,266

56.8

(54.1–59.4)¶

0.0

Hispanic or Latino

3,355

54.4

(52.4–56.5)¶

0.7

Asian, single race, not Hispanic or Latino

972

50.3

(45.8–54.7)¶

2.8

Other race/ethnicity

292

62.2

(55.8–68.3)¶

4.6

50–64 yrs

Total

6,349

63.4

(62.0–64.8)

0.6

White, single race, not Hispanic or Latino

3,966

67.3

(65.6–69.0)

1.0

Black, single race, not Hispanic or Latino

1,065

52.7

(48.6–56.8)¶

0.4

Hispanic or Latino

864

50.9

(46.7–55.1)¶

-2.6

Asian, single race, not Hispanic or Latino

323

47.8

(40.9–54.8)¶

-1.0

Other race/ethnicity

131

68.4

(59.0–76.5)

3.5

≥65 yrs

Total

5,069

53.4

(51.5–55.2)

0.6

White, single race, not Hispanic or Latino

3,462

56.3

(54.2–58.5)

1.4

Black, single race, not Hispanic or Latino

765

39.7

(35.6–44.0)¶

-1.8

Hispanic or Latino

545

43.8

(39.1–48.6)¶

-2.8

Asian, single race, not Hispanic or Latino

241

36.5

(29.2–44.5)¶

-1.7

Other race/ethnicity

56

62.0

(46.7–75.2)

-9.0

TABLE 1. (Continued) Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* and race/ethnicity† — National Health Interview Survey, United States, 2010

Characteristic

Sample size

%

(95% CI)

Difference from 2009

Tetanus vaccination, including pertussis vaccine, past 5 yrs††

19–64 yrs

Total

14,824

8.2

(7.6–8.8)

1.6§§

White, single race, not Hispanic or Latino

7,830

9.1

(8.3–9.9)

1.7§§

Black, single race, not Hispanic or Latino

2,441

7.4

(6.1–8.8)¶

1.6

Hispanic or Latino

3,183

4.8

(3.9–5.9)¶

0.1

Asian, single race, not Hispanic or Latino

1,058

9.2

(6.9–12.1)

4.8§§

Other race/ethnicity

312

8.4

(5.7–12.4)

1.4

Living with an infant aged <1 yr

624

10.6

(7.9–14.2)

0.3

Not living with an infant aged <1 yr

14,200

8.1

(7.5–8.7)

1.7§§

Hepatitis A vaccination (≥2 doses), ever¶¶

19–49 yrs

Total

12,607

10.7

(10.0–11.5)

0.9

White, single race, not Hispanic or Latino

6,432

10.4

(9.4–11.4)

0.5

Black, single race, not Hispanic or Latino

2,068

10.3

(8.8–12.0)

1.5

Hispanic or Latino

3,012

10.3

(8.9–12.0)

1.8

Asian, single race, not Hispanic or Latino

846

15.3

(12.2–19.0)¶

-0.5

Other race/ethnicity

249

16.5

(11.3–23.3)¶

4.7

Had traveled outside the United States (except to Europe, Japan, Australia, New Zealand, or Canada) since 1995

4,595

16.6

(15.2–18.2)

1.6

Had not traveled outside the United States (except to Europe, Japan, Australia, New Zealand, or Canada) since 1995

7,998

7.5

(6.7–8.3)

0.3

High risk, overall

981

14.6

(12.1–17.6)

0.4

With chronic liver conditions, overall

100

19.7

(11.8–31.1)

-1.9

Hepatitis B vaccination (≥3 doses), ever***

19–49 yrs, high risk

Total

1,023

42.0

(38.3–45.8)

0.2

White, single race, not Hispanic or Latino

504

44.5

(39.4–49.8)

1.7

Black, single race, not Hispanic or Latino

242

41.6

(35.0–48.5)

-1.6

Hispanic or Latino

208

33.8

(26.2–42.3)¶

-2.9

Asian, single race, not Hispanic or Latino

40

40.2

(25.5–56.9)

13.6

Other race/ethnicity

—†††

—

—

—

19–59 yrs, with diabetes, overall

1,045

22.8

(19.9–25.9)

-0.3

≥60 yrs, with diabetes, overall

1,480

10.9

(9.2–13.0)

0.8

19–49 yrs, non-high risk

Total

11,941

33.1

(32.0–34.3)

-0.6

White, single race, not Hispanic or Latino

6,089

34.9

(33.4–36.4)

-0.7

Black, single race, not Hispanic or Latino

1,873

33.6

(31.0–36.3)

-1.7

Hispanic or Latino

2,867

24.7

(22.7–26.9)¶

0.4

Asian, single race, not Hispanic or Latino

884

37.2

(33.2–41.5)

0.7

Other race/ethnicity

228

37.9

(29.9–46.6)

-0.8

TABLE 1. (Continued) Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* and race/ethnicity† — National Health Interview Survey, United States, 2010

* Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; or they had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months or had an asthma episode or attack; or they were current smokers. Adults were considered at high risk for hepatitis A or B if they had hemophilia and had received clotting factor concentrations, were a man who had sex with other men, had taken street drugs by needle, had traded sex for money or drugs, had tested positive for human immunodeficiency virus (HIV), or had sex with someone who would meet any of the previous criteria; considered themselves at high risk for HIV infection, or reported having a sexually transmitted diseases other than HIV or acquired immune deficiency syndrome (AIDS) during the previous 5 years.

† Persons of Hispanic or Latino ethnicity might be of any race or combination of races. Other race/ethnicity included American Indian/Alaska Native and multiple races.

§ Respondents were asked if they had ever had a pneumonia shot.

¶ p<0.05 by t-test for comparisons with non-Hispanic white as the reference.

** Respondents were asked if they had received a tetanus shot in the past 10 years. Respondents included adults who received tetanus-diphtheria toxoid (Td) during the past 10 years or tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during 2005–2010.

TABLE 1. (Continued) Estimated proportion of adults aged ≥19 years who received selected vaccinations, by age group, high-risk status,* and race/ethnicity† — National Health Interview Survey, United States, 2010

Characteristic

Sample size

%

(95% CI)

Difference from 2009

†† Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received a tetanus shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 21,041 respondents aged 19–64 years, those without a "yes" or "no" classification for tetanus vaccination status within the preceding 10 years (n = 1,081 [5.1%]), for tetanus vaccination status during 2005–2010 (n = 589 [2.8%]), or Tdap vaccine status during 2005–2010 (n = 4,789 [22.8%]) were excluded, yielding a sample of 14,582 respondents aged 19–64 years for whom Tdap vaccination status could be assessed. Advisory Committee on Immunization Practices (ACIP) recommendations on use of Tdap in certain adults aged ≥65 years are available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_w.

§§ p<0.05 by t-test for comparisons between 2010 and 2009 within each level of each characteristic.

¶¶ Respondents were asked if they had ever received the hepatitis A vaccine, and if yes, how many shots were received.

*** Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received ≥3 doses or <3 doses.

††† Estimates are not reliable because of small sample size (n<30) or relative standard error (standard error/estimates) >0.3.

§§§ Respondents were asked if they had ever received a shingles vaccine.

¶¶¶ Respondents were asked if they had ever received the HPV shot or cervical cancer vaccine.

**** Data not applicable.

TABLE 2. Type of tetanus vaccine received and proportions that were tetanus, diphtheria, acellular pertussis (Tdap) vaccine, among adults aged 19–64 years who received a tetanus vaccination, by selected characteristics — National Health Interview Survey, United States, 2010

Characteristic

Type of vaccine received among those who received a tetanus vaccination during 2005–2010

Proportions of total tetanus vaccinations during 2005–2010* that were Tdap

No. in sample

Received Tdap

Received other tetanus vaccine

Doctor did not inform the patient

Could not recall vaccine type

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

No. in sample

%

(95% CI)

Adults aged 19–64 yrs

7,088

16.5

(15.4–17.6)

15.1

(14.0–16.1)

58.9

(57.3–60.5)

9.6

(8.7–10.5)

2,198

52.3

(49.6–54.9)

Health-care personnel

887

31.3

(27.7–35.1)

18.2

(15.3–21.6)

42.4

(38.3–46.6)

8.1

(6.3–10.4)

432

63.2†

(57.5–68.5)

Abbreviation: CI = confidence interval.

* Calculated by dividing number of respondents who reported receiving Tdap by the sum of those who reported receiving Tdap and those who reported receiving other tetanus vaccination; respondents who reported that the doctor did not inform them of the vaccine type they received and those who could not recall the vaccine type were excluded.

† p<0.05 by t-test for comparisons between health-care personnel and all adults aged 19–64 years.

* Adults were classified as HCP if they currently volunteer or work in a hospital, medical clinic, doctor's office, dentist's office, nursing home, or some other health-care facility including part-time and unpaid work in a health-care facility or professional nursing care provided in the home.

† Persons of Hispanic or Latino ethnicity might be of any race or combination of races. Other race/ethnicity included American Indian/Alaska Native and multiple races.

§ Respondents who had received a tetanus shot in the past 10 years were asked if their most recent shot was given in 2005 or later. Respondents who had received a tetanus shot since 2005 were asked if they were told that their most recent tetanus shot included the pertussis or whooping cough vaccine. Among 1,850 HCP aged 19–64 years, those without a "yes" or "no" classification for tetanus vaccination status within the preceding 10 years (n = 47 [2.5%]), for tetanus vaccination status during 2005–2010 (n = 61 [3.3%]), or tetanus, diphtheria, and acellular pertussis (Tdap) vaccine status during 2005–2010 (n = 451 [24.4%]) were excluded, yielding a sample of 1,427 respondents aged 19–64 years for whom Tdap vaccination status could be assessed. Advisory Committee on Immunization Practices (ACIP) recommendations on use of Tdap in certain adults aged ≥65 years are available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_w.

¶ p<0.05 by t-test for comparisons between 2010 and 2009 within each level of each characteristic.

** p<0.05 by t-test for comparisons with non-Hispanic white as the reference.

†† Estimates are not reliable because of small sample size (n <30) or relative standard error (standard error/estimates) >0.3.

§§ Respondents were asked if they had ever received the hepatitis B vaccine, and if yes, if they had received >3 doses or <3 doses.

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